Healthcare Provider Details

I. General information

NPI: 1942209770
Provider Name (Legal Business Name): KYUNG LEE BOEN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 03/17/2019
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/22/2006

III. Provider practice location address

1786 AVENIDA REGINA
SAN MARCOS CA
92069
US

IV. Provider business mailing address

1786 AVENIDA REGINA
SAN MARCOS CA
92069-4209
US

V. Phone/Fax

Practice location:
  • Phone: 760-212-2276
  • Fax:
Mailing address:
  • Phone: 760-212-2276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number52181
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: